Provider Demographics
NPI:1548216484
Name:CEREBRAL PALSY, INC.
Entity Type:Organization
Organization Name:CEREBRAL PALSY, INC.
Other - Org Name:CP CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:SYNDERGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-337-1122
Mailing Address - Street 1:2801 S WEBSTER AVE
Mailing Address - Street 2:BILLING DEPARTMENT
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2878
Mailing Address - Country:US
Mailing Address - Phone:920-337-1122
Mailing Address - Fax:920-337-1126
Practice Address - Street 1:2801 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2878
Practice Address - Country:US
Practice Address - Phone:920-337-1122
Practice Address - Fax:920-337-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41810300Medicaid
WI41810300Medicaid